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V.

treatment.

aportance

Dr. Cheyne, in like manner, regards convulsions as a Gen. VIII. source of great danger: while M. Portal, on the contrary, Spec.

!B C. Apothinks they sometimes announce a diminution of the mor- plexia atobid cause. The latter reasons from the fact that when, in nica...

Atonic apoliving animals, a slight pressure has been made on the ex- plexy. posed brain, convulsions have taken place; while, if the Convulsio pressure be increased in power, general stupor with ster- dangerous. tor and difficult respiration have followed instead of convulsions; an ingenious conclusion but not exactly applicable, since in the one case the brain is in a morbid and in the other in a sound state; whence the premises on which the reasoning is founded are not parallel.

In the treatment of apoplexy, if we be timely consulted Medical during the existence of the precursive signs which have in been noticed as occasionally taking place, we shall often of a timely

attention to find it in our power completely to ward off a paroxysm by the precurbleeding, purgatives, perfect quiet, and, in the entonic sive signs. variety, a reducent regimen. Where, however, the pulse, Bleeding and other symptoms give proof of weak vascular action, when to be

pursued with and nervous debility, the depleting plan should be pur- caution. sued with caution, and it will be better to employ cuppingglasses than venesection, and, in some instances, to limit ourselves to purgatives alone. Yet, whatever be the de- When absogree of general debility, if the proofs of compression or

P Colon or sary even in distention be clear, as those of drowsiness, vertigo, and a atonic apodull pain in the head, it will be as necessary to have recourse to bleeding either locally or generally, as in entonic apoplexy; for such symptoms will assuredly lead to a fit, unless timely counteracted and subdued. .“ In the actual paroxysm of apoplexy,” says Dr. G

rections, Cooke, and I quote his words because it is impossible to exchange them for better, “ the patient should, if possible, be immediately carried into a spacious apartment, into which cool air may be freely admitted. He should be placed in a posture which the least favours determination of blood to the head: all ligatures, especially those about the neck, should be speedily removed, and the legs and feet should be placed in warm water, or rubbed with stimulating applications. These means may be employed in all cases

lutely neces

General di

pocrates.

GEN. VIII. of apoplexy**: and are consequently equally applicable to

Spec. V.
Carus Apo. both the forms under which we have contemplated the dis-
plexia. ease. The collateral means to be had recourse to require
Apoplexy.
Treatment.

discrimination, and it will be most convenient to consider
them in relation to the actual form under which the apo-

plexy presents itself. Particular

In ENTONIC APOPLEXY, copious and repeated bleeding treatment of entonic seems, primâ facie, to offer the most rapid and effectual apoplexy.

remedy we can have recourse to: yet the opinions of the Copious and repeated

'best practitioners, as well in ancient as in modern times, bleeding.

have been strangely at variance upon this subject. Hippocrates, who regarded apoplexy as chiefly dependent upon a weak and pituitous habit, discountenanced the use of the lancet, as adding to the general debility: and even

where it is accompanied with symptoms of strong vascular Timid prac

action, he discountenanced it equally, from an idea that tice of Hip

the case was utterly hopeless when it assumed this form, and that to have recourse to bleeding would only bring a reproach upon the art of medicine. The authority of Hippocrates has had too much influence with physicians in all ages, and has extended its baneful effects to recent

times, and in some instances even to our own day. Hence influence on later physi- Forestus tells us, that in strong or entonic apoplexy, no cians: as Forestus :

courageous plan ought to be attempted, no venesection, no pills: we may, indeed, to please the by-standers, have recourse to the remedia leviora of frictions, and injections, and ligatures round the arms and thighs: “ and where”, says he, “ we have not found these succeed-in rationem sacerdotibus commiserimus.”

In our own country, the same timid feeling has been particularly manifested by Dr. Heberden and Dr. Fothergill, but on grounds somewhat different. These excellent pathologists have chiefly regarded apoplexy as a disease of nervous rather than of general debility, and have been fearful of adding to this debility by abstracting blood, and hereby of almost ensuring hemiplegia, or some other form of paralysis. Hence Dr. Heberden speaks with great

Mischievous

Heberden:

* Burser. p. 288.

hesitation concerning the practice rather than with an ab- Gen. VIII.

Srec, V. solute and general condemnation of it: he observes, which Carus; is true enough, that many persons have been injured by plexia.

Apoplexy. large and repeated bleedings, and then lays down his Treatme rule, not to bleed either in an attack of apoplexy or palsy, if there would have been just objections to taking away blood before the incursion of either*.

Dr. Fothergill, however, expresses himself still more Fothergill. decidedly against bleeding than Dr. Heberden. Ile suspects that the weakness it occasions checks the natural effort to produce absorption ; and that even the liard and full and irregular pulse, which seems imperatively to call for a very free use of the lancct, “is often an insufficient guide”; since “it may be that struggle which arises from an exertion of the vires vite to restore health.” And hence, he adds in another place, “ I am of opinion that bleeding in apoplexy is, for the most part, injurious, and that we should probably render the most effectual aid by endeavouring, in all cases, to procure a plentiful discharge from the bowels : as by these revulsions, the head is, perhaps, much more effectually relieved from plenitude, and that without weakening or interrupting any other effort of nature to relieve herself than by venesection.”+

It is singular that in drawing such conclusions from the instinctive efforts or remedial power of nature, where a cure has been effected spontaneously, these distinguished writers have not felt more deeply impressed by the salu- Salutary eftary efforts of spontaneous and copious hemorrhages, as from the nose, the lungs, and the hemorrhoidal vessels, hemowhich have never perhaps poured forth blood freely with-rrhages. out operating a cure; and that they have not endeavoured to follow these footsteps, as far as they might have done, by substituting an artificial discharge of blood where a natural discharge has not taken place. Other physicians, however, both in ancient and modern Bolder prac

w tice of other times, have not been equaily insensible to this important fact. Galen, though he always hesitated in departing from

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modern:

s an

cient and

Galen,

* Medical Transactions, 1. p. 472.

+ Works, Vol. 10. p. 208.

Car

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Gen. VIII. the practice of Hippocrates, ventured to deviate from him Spec. V.

S: Apo- upon the point before us. Aretxus, Paulus of Ægina, and plexia. Colin

Cælius Aurelianus carried the remedy of bleeding to a

A Apoplexy.

still further extent, and Celsus regarded it as the only

mean of effecting a cure*. Paulus .“ The Arabians adopted the practice of the ancients, Ægineta.

as far as relates to the employment of blood-letting in the Arabian practice. strong apoplexy, and by far the greater number of modern

physicians have, in this respect, followed their example. In support of this practice we might adduce the opinion.

of all who have written on the disease: we might quote Boerhaave, from the works of Sydenham, Wepffer, Boerhaave, Van Morgagni, Hoflinan, Swieten, Morgagni, Baglivi, Sauvages, Tissot, Mead, Cullen,

Freind, Pitcairn, Hoffman, Cullen, Portal, Cheyne, and Portal, Cheyne,

many other eminent modern writers.”+ As this paragraph Cooke.

is quoted from Dr. Cooke, it is almost superfluous to add his own name to the list of those who strenuously recom

mend blood-letting On which . A question has been made as to the side from which side blood may be it may be most advantageous to take blood. Aretæus

drew it from the sound side, wherever this could be disadvantage

tinguished. Valsalva and Morgagni recommend the same; Mostly re-, as does also Cullen, observing that “ dissections show commended from the that congestions producing apoplexy are always on the

side not affected." I Baglivi recommends bleeding from By Baglivi

the diseased side, except where blood is abstracted lofroin the

cally. The question appears to be of no great importance: the grand object in general bleeding is to diminish the quantity and momentum of the circulating fluid, to enable the ruptured vessels to contract with greater facility, and to afford time for an absorption of whatever may have

been effused. Local bleed. In entonic apoplexy, general and local bleeding should ing to ac

hond in hand

go hand in hand; and the quantity drawn should in every company general,

instance depend upon the urgency of the symptoms. Dr. Cheyne advises us to begin with abstracting two pounds,

drawn most

sound side.

diseased side.

To what extent.

* De Medicin. Lib. l. cap. xxvII.

Prut. of Phys. Vol. ur. p. 184.

+ Cooke, ut suprà, 292.

1.

and tells us that it will often require a loss of six or eight Gen. VIII.

Spec. V. pounds before the disease will give way.

Carus ApoDr. Cullen, and many other writers, as Morgagni, Val- plexia.

Apoplexy. salva, and Portal, have recommended that the opening Treatment. should be made in the temporal artery or the jugular Temporal veins. “ In all cases of a full habit,” says Dr. Cullen, artery. “ and where the disease has been preceded by marks of a ;

Jugular plethoric state, blood-letting is to be immediately employed, and very largely. In my opinion it will be most effectual when the blood is taken from the jugular vein ; but if that cannot be done, it may be taken from the arm. The opening of the temporal artery, when a large branch can be opened so as suddenly to pour out a considerable quantity of blood, may also be an effectual remedy ; but, in execution, it is more uncertain, and may be inconvenient. It may in some measure be supplied by cupping and scarifying on the temples or hind-head. This, indeed, should seldom be omitted, and these scarifications are always preferable to the application of leeches”. *

In bleeding from the temporal artery we may safely let the stream flow as long as it will, for in common it will cease before we have obtained enough, and all tight ligatures about the head, or indeed any other part of the body, should be avoided as much as possible. For the same reason Heister advises that, on opening the jugular vein, no ligature should be made use of, as the smallest pressure on the part may do harm by interrupting the circulation of the blood on the external veins of the neck.

M. Dejean, of Caen, proposed, not long ago, to the Opening of Academy of Sciences, to open the superior longitudinal longitudinal

the superior sinus after raising the bone which covers it, and asserted sinus, prothat he had employed this mode with great success on Dejean? but

posed by strangled dogs. M. Portal, and M. Tenon, however, who were appointed commissioners to report on M. De- Portal and

mended by jean's memoir, agreed that bleeding from the jugular Tenon. vein is preferable to that from the sinus, as producing the

* Pract. of Phys. Vol. II. p. 182.

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